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Crippa IA, Vincent JL, Zama Cavicchi F, Pozzebon S, Gaspard N, Maenhout C, Creteur J, Taccone FS. Estimated Cerebral Perfusion Pressure and Intracranial Pressure in Septic Patients. Neurocrit Care 2024; 40:577-586. [PMID: 37420137 DOI: 10.1007/s12028-023-01783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/09/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Sepsis-associated brain dysfunction (SABD) is frequent and is associated with poor outcome. Changes in brain hemodynamics remain poorly described in this setting. The aim of this study was to investigate the alterations of cerebral perfusion pressure and intracranial pressure in a cohort of septic patients. METHODS We conducted a retrospective analysis of prospectively collected data in septic adults admitted to our intensive care unit (ICU). We included patients in whom transcranial Doppler recording performed within 48 h from diagnosis of sepsis was available. Exclusion criteria were intracranial disease, known vascular stenosis, cardiac arrhythmias, pacemaker, mechanical cardiac support, severe hypotension, and severe hypocapnia or hypercapnia. SABD was clinically diagnosed by the attending physician, anytime during the ICU stay. Estimated cerebral perfusion pressure (eCPP) and estimated intracranial pressure (eICP) were calculated from the blood flow velocity of the middle cerebral artery and invasive arterial pressure using a previously validated formula. Normal eCPP was defined as eCPP ≥ 60 mm Hg, low eCPP was defined as eCPP < 60 mm Hg; normal eICP was defined as eICP ≤ 20 mm Hg, and high eICP was defined as eICP > 20 mm Hg. RESULTS A total of 132 patients were included in the final analysis (71% male, median [interquartile range (IQR)] age was 64 [52-71] years, median [IQR] Acute Physiology and Chronic Health Evaluation II score on admission was 21 [15-28]). Sixty-nine (49%) patients developed SABD during the ICU stay, and 38 (29%) were dead at hospital discharge. Transcranial Doppler recording lasted 9 (IQR 7-12) min. Median (IQR) eCPP was 63 (58-71) mm Hg in the cohort; 44 of 132 (33%) patients had low eCPP. Median (IQR) eICP was 8 (4-13) mm Hg; five (4%) patients had high eICP. SABD occurrence and in-hospital mortality did not differ between patients with normal eCPP and patients with low eCPP or between patients with normal eICP and patients with high eICP. Eighty-six (65%) patients had normal eCPP and normal eICP, 41 (31%) patients had low eCPP and normal eICP, three (2%) patients had low eCPP and high eICP, and two (2%) patients had normal eCPP and high eICP; however, SABD occurrence and in-hospital mortality were not significantly different among these subgroups. CONCLUSIONS Brain hemodynamics, in particular CPP, were altered in one third of critically ill septic patients at a steady state of monitoring performed early during the course of sepsis. However, these alterations were equally common in patients who developed or did not develop SABD during the ICU stay and in patients with favorable or unfavorable outcome.
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Affiliation(s)
- Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Anesthesiology and Intensive Care, Policlinico San Marco, Gruppo San Donato, Corso Europa 7, 24046, Zingonia, Italy.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Federica Zama Cavicchi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Selene Pozzebon
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Christelle Maenhout
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
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Duodenum edema due to reduced lymphatic drainage leads to increased inflammation in a porcine endotoxemic model. Intensive Care Med Exp 2022; 10:17. [PMID: 35501517 PMCID: PMC9061929 DOI: 10.1186/s40635-022-00444-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Interventions, such as mechanical ventilation with high positive end-expiratory pressure (PEEP), increase inflammation in abdominal organs. This effect could be due to reduced venous return and impaired splanchnic perfusion, or intestinal edema by reduced lymphatic drainage. However, it is not clear whether abdominal edema per se leads to increased intestinal inflammation when perfusion is normal. The aim of the presented study was to investigate if an impaired thoracic duct function can induce edema of the abdominal organs and if it is associated to increase inflammation when perfusion is maintained normal. In a porcine model, endotoxin was used to induce systemic inflammation. In the Edema group (n = 6) the abdominal portion of the thoracic duct was ligated, while in the Control group (7 animals) it was maintained intact. Half of the animals underwent a diffusion weighted-magnetic resonance imaging (DW-MRI) at the end of the 6-h observation period to determine the abdominal organ perfusion. Edema in abdominal organs was assessed using wet–dry weight and with MRI. Inflammation was assessed by measuring cytokine concentrations in abdominal organs and blood as well as histopathological analysis of the abdominal organs. Results Organ perfusion was similar in both groups, but the Edema group had more intestinal (duodenum) edema, ascites, higher intra-abdominal pressure (IAP) at the end of observation time, and higher cytokine concentration in the small intestine. Systemic cytokines (from blood samples) correlated with IAP. Conclusions In this experimental endotoxemic porcine model, the thoracic duct’s ligation enhanced edema formation in the duodenum, and it was associated with increased inflammation.
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Taccone FS, Su F, He X, Peluso L, Donadello K, Scolletta S, De Backer D, Vincent JL. Effects of Reversal of Hypotension on Cerebral Microcirculation and Metabolism in Experimental Sepsis. Biomedicines 2022; 10:biomedicines10040923. [PMID: 35453673 PMCID: PMC9032351 DOI: 10.3390/biomedicines10040923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 12/28/2022] Open
Abstract
The effects of reversal of hypotension on the cerebral microcirculation, oxygenation, and metabolism in septic shock remain unclear. In 12 sheep, peritonitis was induced by injection of feces into the abdominal cavity. At the onset of septic shock (mean arterial pressure (MAP) < 65 mmHg, unresponsive to fluid challenge), a norepinephrine infusion was titrated in eight sheep to restore a MAP ≥ 75 mmHg; the other four sheep were kept hypotensive. The microcirculation of the cerebral cortex was evaluated using side-stream dark-field video-microscopy. Brain partial pressure of oxygen (PbtO2) was measured, and cerebral metabolism was assessed using microdialysis. All animals developed septic shock after a median of 15 (14−19) h. When MAP was raised using norepinephrine, the PbtO2 increased significantly (from 41 ± 4 to 55 ± 5 mmHg), and the cerebral lactate/pyruvate ratio decreased (from 47 ± 13 to 28 ± 4) compared with values at shock onset. Changes in the microcirculation were unchanged with restoration of MAP and the glutamate increased further (from 17 ± 11 to 23 ± 16 μM), as it did in the untreated animals. In septic shock, the correction of hypotension with vasopressors may improve cerebral oxygenation but does not reverse the alterations in brain microcirculation or cerebral metabolism.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (L.P.); (K.D.); (J.-L.V.)
- Laboratoire Experimental des Soins Intensifs, Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (F.S.); (X.H.); (S.S.); (D.D.B.)
- Correspondence: ; Tel.: +32-25-554-445
| | - Fuhong Su
- Laboratoire Experimental des Soins Intensifs, Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (F.S.); (X.H.); (S.S.); (D.D.B.)
| | - Xinrong He
- Laboratoire Experimental des Soins Intensifs, Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (F.S.); (X.H.); (S.S.); (D.D.B.)
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (L.P.); (K.D.); (J.-L.V.)
| | - Katia Donadello
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (L.P.); (K.D.); (J.-L.V.)
- Unit of Anesthesiology and Intensive Care B, AOUI-University Hospital Integrated Trust of Verona, University of Verona, 37129 Verona, Italy
| | - Sabino Scolletta
- Laboratoire Experimental des Soins Intensifs, Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (F.S.); (X.H.); (S.S.); (D.D.B.)
- Anestesia e Terapia Intensiva, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy
| | - Daniel De Backer
- Laboratoire Experimental des Soins Intensifs, Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (F.S.); (X.H.); (S.S.); (D.D.B.)
- Intensive Care Department, CHIREC Hospitals, 1160 Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (L.P.); (K.D.); (J.-L.V.)
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